Longitudinal Study of Psychiatric Symptoms, Disability, Mortality, and Emigration Among Bosnian Refugees

CONTEXT Evidence is emerging that psychiatric disorders are common in populations affected by mass violence. Previously, we found associations among depression, posttraumatic stress disorder (PTSD), and disability in a Bosnian refugee cohort. OBJECTIVE To investigate whether previously observed associations continue over time and are associated with mortality emigration to another region. DESIGN, SETTING, AND PARTICIPANTS Three-year follow-up study conducted in 1999 among 534 adult Bosnian refugees originally living in a refugee camp in Croatia. At follow-up, 376 (70.4%) remained living in the region, 39 (7.3%) were deceased, 114 (21.3%) had emigrated, and 5 (1%) were lost to follow-up. Those still living in the region and the families of the deceased were reinterviewed (77.7% of the original participants). MAIN OUTCOME MEASURES Depression and PTSD diagnoses, based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria and measured by the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire, respectively; disability, measured by the Medical Outcomes Study Short-Form 20; and cause of death, determined by family interviews with review of death certificates, if available. RESULTS In 1999, 45% of the original respondents who met the DSM-IV criteria for depression, PTSD, or both continued to have these disorders and 16% of respondents who were asymptomatic in 1996 developed 1 or both disorders. Forty-six percent of those who initially met disability criteria remained disabled. Log-linear analysis revealed that disability and psychiatric disorder were related at both times. Male sex, isolation from family, and older age were associated with increased mortality after adjusting for demographic characteristics, trauma history, and health status (for male sex, adjusted odds ratio [OR], 2.63; 95% confidence interval [CI], 1.17-5.92; living alone, OR, 2.40; 95% CI, 1.07-5.38; and each 10-year increase in age, OR, 1.91; 95% CI, 1.34-2.71). Depression was associated with higher mortality in unadjusted analysis but was not after statistical adjustment (unadjusted OR, 3.12; 95% CI, 1.55-6.26; adjusted OR, 1.85; 95% CI, 0.82-4.16). Posttraumatic stress disorder was not associated with mortality or emigration. Spending less than 12 months in the refugee camp (OR, 11.30; 95% CI, 6.55-19.50), experiencing 6 or more trauma events (OR, 3.34; 95% CI, 1.89-5.91), having higher education (OR, 1.90; 95% CI, 1.10-3.29), and not having